{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,9]],"date-time":"2026-10-09T06:09:20Z","timestamp":1791526160439,"version":"4.3.4"},"update-to":[{"DOI":"10.1371\/journal.pntd.0012265","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2024,7,16]],"date-time":"2024-07-16T00:00:00Z","timestamp":1721088000000}}],"reference-count":40,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2024,7,3]],"date-time":"2024-07-03T00:00:00Z","timestamp":1719964800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100011061","name":"Agence Fran\u00e7aise de D\u00e9veloppement","doi-asserted-by":"publisher","award":["EVA\/364-2015"],"award-info":[{"award-number":["EVA\/364-2015"]}],"id":[{"id":"10.13039\/501100011061","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100011560","name":"Fondation Veolia Environnement","doi-asserted-by":"publisher","award":["13\/14 HD 1123"],"award-info":[{"award-number":["13\/14 HD 1123"]}],"id":[{"id":"10.13039\/501100011560","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosntds.org"],"crossmark-restriction":false},"short-container-title":["PLoS Negl Trop Dis"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Safely managed drinking water is critical to prevent diarrhoeal diseases, including cholera, but evidence on the effectiveness of piped water supply in reducing these diseases in low-income and complex emergency settings remains scarce.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>We conducted a trial of water supply infrastructure improvements in Uvira (DRC). Our primary objective was to estimate the relationship between a composite index of water service quality and the monthly number of suspected cholera cases admitted to treatment facilities and, as a secondary analysis, the number of cases confirmed by rapid diagnostic tests. Other exposures included the quantity of supplied water and service continuity. We used Poisson generalised linear models with generalised estimating equations to estimate incidence rate ratios.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Findings<\/jats:title>\n<jats:p>Associations between suspected cholera incidence and water service quality (RR 0\u00b786, 95% CI 0\u00b773\u20131\u00b701), quantity (RR 0\u00b780, 95% CI 0\u00b762\u20131\u00b702) and continuity (RR 0\u00b781, 95% CI 0\u00b777\u20130\u00b786) were estimated. The magnitudes of the associations were similar between confirmed cholera incidence and water service quality (RR 0\u00b784, 95% CI 0\u00b773\u20130\u00b797), quantity (RR 0\u00b776, 95% CI 0\u00b761\u20130\u00b794) and continuity (RR 0\u00b775, 95% CI 0\u00b769\u20130\u00b781). These results suggest that an additional 5 L\/user\/day or 1.2 hour per day of water production could reduce confirmed cholera by 24% (95% CI 6\u201339%) and 25% (95% CI 19\u201331%), respectively.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Interpretation<\/jats:title>\n<jats:p>Ensuring a sufficient and continuous piped water supply may substantially reduce the burden of endemic cholera and diarrhoeal diseases but evaluating this rigorously is challenging. Pragmatic strategies are needed for public health research on complex interventions in protracted emergency settings.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec005\">\n<jats:title>Trial registration<\/jats:title>\n<jats:p>The trial is registered in ClinicalTrials.gov ID <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/classic.clinicaltrials.gov\/ct2\/show\/NCT02928341\" xlink:type=\"simple\">NCT02928341<\/jats:ext-link>. <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/classic.clinicaltrials.gov\/ct2\/show\/NCT02928341\" xlink:type=\"simple\">https:\/\/classic.clinicaltrials.gov\/ct2\/show\/NCT02928341<\/jats:ext-link>.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pntd.0012265","type":"journal-article","created":{"date-parts":[[2024,7,3]],"date-time":"2024-07-03T17:36:31Z","timestamp":1720028191000},"page":"e0012265","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":6,"title":["Improved water supply infrastructure to reduce acute diarrhoeal diseases and cholera in Uvira, Democratic Republic of the Congo: Results and lessons learned from a pragmatic trial"],"prefix":"10.1371","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6412-1483","authenticated-orcid":true,"given":"Karin","family":"Gallandat","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amy","family":"Macdougall","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aur\u00e9lie","family":"Jeandron","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jaime","family":"Mufitini Saidi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Baron","family":"Bashige Rumedeka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Espoir Bwenge","family":"Malembaka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew S.","family":"Azman","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Didier","family":"Bompangue","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simon","family":"Cousens","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Allen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Oliver","family":"Cumming","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2024,7,3]]},"reference":[{"issue":"9","key":"pntd.0012265.ref001","doi-asserted-by":"crossref","first-page":"909","DOI":"10.1016\/S1473-3099(17)30276-1","article-title":"Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015","volume":"17","author":"C Troeger","year":"2017","journal-title":"The Lancet Infectious Diseases"},{"issue":"6","key":"pntd.0012265.ref002","article-title":"Updated Global Burden of Cholera in Endemic Countries","volume":"9","author":"M Ali","year":"2015","journal-title":"PLoS Negl Trop Dis"},{"issue":"10133","key":"pntd.0012265.ref003","doi-asserted-by":"crossref","first-page":"1908","DOI":"10.1016\/S0140-6736(17)33050-7","article-title":"Mapping the burden of cholera in sub-Saharan Africa and implications for control: an analysis of data across geographical scales","volume":"391","author":"J Lessler","year":"2018","journal-title":"The Lancet"},{"key":"pntd.0012265.ref004","doi-asserted-by":"crossref","first-page":"A13","DOI":"10.1016\/j.vaccine.2019.07.036","article-title":"Cholera surveillance and estimation of burden of cholera","volume":"38","author":"D Ganesan","year":"2020","journal-title":"Vaccine"},{"key":"pntd.0012265.ref005","unstructured":"Global Task Force on Cholera Control (GTFCC). 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[cited 2023 Jul 15]. Available from: http:\/\/www.rulac.org\/news\/democratic-republic-of-the-congo-a-mapping-of-non-international-armed-confl"},{"key":"pntd.0012265.ref020","unstructured":"Internal Displacement Monitoring Centre. Internal Displacement \u2010 Country Profile \u2010 Democratic Republic of the Congo [Internet]. 2019 [cited 2023 Jul 15]. Available from: https:\/\/www.internal-displacement.org\/countries\/democratic-republic-of-the-congo"},{"key":"pntd.0012265.ref021","unstructured":"Agence Fran\u00e7aise de D\u00e9veloppement (AFD). Note de communication publique d\u2019op\u00e9ration. R\u00e9publique D\u00e9mocratique du Congo. 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Crue exceptionnelle de la rivi\u00e8re Mulongwe, Uvira\/RDC, 17 avril 2020. 2020."},{"key":"pntd.0012265.ref025","article-title":"Enqu\u00eate d\u2019\u00e9valuation des changements d\u2019acc\u00e8s aux services d\u2019eau, hygi\u00e8ne et assainissement suite aux inondations extr\u00eames d\u2019avrili 2020 \u00e0 Uvira, Sud-Kivu, R\u00e9publique D\u00e9mocratique du Congo","author":"K Gallandat","year":"2020","journal-title":"(Report available from the authors.)"},{"key":"pntd.0012265.ref026","article-title":"Evaluation de l\u2019impact sur les maladies diarrh\u00e9iques de l\u2019am\u00e9lioration de l\u2019approvisionnement en eau de la ville d\u2019Uvira, R\u00e9publique D\u00e9mocratique du Congo (RDC)","author":"K Gallandat","year":"2022","journal-title":"Enqu\u00eate aupr\u00e8s des m\u00e9nages sur les pratiques domestiques li\u00e9es \u00e0 l\u2019eau"},{"issue":"8","key":"pntd.0012265.ref027","doi-asserted-by":"crossref","first-page":"e0201306","DOI":"10.1371\/journal.pone.0201306","article-title":"Confirmation of cholera by rapid diagnostic test amongst patients admitted to the cholera treatment centre in Uvira, Democratic Republic of the Congo","volume":"13","author":"A Jeandron","year":"2018","journal-title":"PLOS ONE"},{"issue":"8","key":"pntd.0012265.ref028","doi-asserted-by":"crossref","first-page":"3939","DOI":"10.1128\/JCM.41.8.3939-3941.2003","article-title":"Use of Dipsticks for Rapid Diagnosis of Cholera Caused by Vibrio cholerae O1 and O139 from Rectal Swabs","volume":"41","author":"NA Bhuiyan","year":"2003","journal-title":"Journal of Clinical Microbiology"},{"issue":"2","key":"pntd.0012265.ref029","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1016\/j.cmi.2021.08.027","article-title":"Accuracy of cholera rapid diagnostic tests: a systematic review and meta-analysis","volume":"28","author":"BA Muzembo","year":"2022","journal-title":"Clinical Microbiology and Infection"},{"key":"pntd.0012265.ref030","doi-asserted-by":"crossref","first-page":"120316","DOI":"10.1016\/j.watres.2023.120316","article-title":"A fuzzy inference-based index for piped water supply service quality in a complex, low-income urban setting","volume":"243","author":"M Gaiffe","year":"2023","journal-title":"Water Research"},{"key":"pntd.0012265.ref031","author":"G Howard","year":"2020","journal-title":"Domestic water quantity, service level and health"},{"issue":"741","key":"pntd.0012265.ref032","article-title":"Prevalence and diversity of enteric infections among cholera treatment centre patients with acute diarrhea in Uvira, Democratic Republic of Congo","volume":"20","author":"C Williams","year":"2020","journal-title":"BMC Infectious Diseases"},{"issue":"4","key":"pntd.0012265.ref033","doi-asserted-by":"crossref","first-page":"1198","DOI":"10.1111\/j.0006-341X.2001.01198.x","article-title":"Small-sample adjustments for Wald-type tests using sandwich estimators","volume":"57","author":"MP Fay","year":"2001","journal-title":"Biometrics"},{"key":"pntd.0012265.ref034","article-title":"Challenges with Achieving and Maintaining High Oral Cholera Vaccine Coverage in Uvira, The Democratic Republic of the Congo: serial cross-sectional representative surveys","author":"A Koyuncu","year":"2024","journal-title":"OSF Pre-Print"},{"key":"pntd.0012265.ref035","unstructured":"R Core Team. 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